Comparison of cardiac rehabilitation outcomes in individuals with respiratory, cardiac or no comorbidities: A retrospective review

Although currently major contributors to morbidity and mortality, cardiovascular disease (CVD) and chronic respiratory diseases, such as chronic obstructive pulmonary disease, are projected to rank among the top three in global disease burden by 2020. Multimorbidity is a common feature in CVD and chronic respiratory disease, and patients often share the same pathological characteristics including anatomical location of disease, dyspnea and fatigue, among several others. However, patients entering rehabilitation programs for either condition are functionally diverse; therefore, individuals with respiratory comorbidities may not fare as well in cardiac rehabilitation programs. This retrospective cohort study investigated several relevant functional parameters and outcomes

Profile of women choosing mixed-sex women-only, and home-based cardiac rehabilitation models and impact on utilization

This study compared characteristics and program utilization in women electing to participate in mixed-sex, women-only, or home-based cardiac rehabilitation (CR). In this retrospective cohort study, electronic records of CR participants in Toronto who were offered the choice of program model between January 2017-February 2020 were analyzed. There were 727 women (74.7% mixed, 22.0% women-only, 3.3% home-based) who initiated CR. There were significantly more women who were not working in women-only than mixed-sex (80.4% vs 64.1%; P=.009). Session adherence was significantly greater with mixed-sex (58.8±28.9% sessions attended/25) than women-only (54.3±26.3% sessions attended/25; P=.046); program completion was significantly lower with home-based (33.3%) than either supervised model (59.7%; P=.035). Participation in women-only CR may be less accessible. Further research is needed to investigate offering remote women-focused sessions or peer support.Sherry L. Grace is supported in her work by the Toronto General & Toronto Western Hospital Foundation and the Peter Munk Cardiac Centre, University Health Network

Exercise Training Increases Parietal Lobe Cerebral Blood Flow in Chronic Stroke: An Observational Study

Exercise is increasingly recommended as an essential component of stroke rehabilitation, yet uncertainty remains with respect to its direct effect on the cerebral vasculature. The current study first demonstrated the repeatability of pseudo-continuous arterial spin labeling (ASL) magnetic resonance imaging (MRI) in older adults with stroke, and then investigated the change in cerebrovascular function following a 6-month cardiovascular rehabilitation program. In the repeatability study, 12 participants at least 3 months post-stroke underwent two ASL imaging scans 1 month apart. In the prospective observational study, eight individuals underwent ASL imaging and aerobic fitness testing before and after a 6-month cardiovascular rehabilitation program. Cerebral blood flow (CBF) and the spatial coefficient of variation of CBF (sCoV) were quantified to characterize tissue-level perfusion and large cerebral artery transit time properties, respectively. In repeat scanning, intraclass correlation (ICC) indicated moderate test-retest reliability for global gray matter CBF (ICC = 0.73) and excellent reliability for sCoV (ICC = 0.94). In the observational study, gray matter CBF increased after training (baseline: 40 ± 13 vs. 6-month: 46 ± 12 ml·100 g−1·min−1, P = 0.036). The greatest change occurred in the parietal lobe (+18 ± 12%). Gray matter sCoV, however, did not change following training (P = 0.31). This study provides preliminary evidence that exercise-based rehabilitation in chronic stroke enhances tissue-level perfusion, without changing the relative hemodynamic properties of the large cerebral arteries

ICCPR Guideline: Women-Focused CR

Women-focused cardiovascular rehabilitation (CR; phase II) aims to better engage women, and may result in better quality-of-life than traditional programs. This first clinical practice guideline by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) provides guidance on how to deliver women-focused programming. The writing panel comprised experts with diverse geographic representation, including multidisciplinary healthcare providers, a policy-maker, and patient partners. The guideline was developed in accordance with AGREE II and RIGHT. Initial recommendations were based on a meta-analysis. These were circulated to a Delphi panel (comprised of corresponding authors from review articles and of programs delivering women-focused CR identified through ICCPR’s audit; N=76), who were asked to rate each on a 7-point Likert scale in terms of impact and implementability (higher scores positive). A webcall was convened to achieve consensus; 15 panelists confirmed strength of revised recommendations (GRADE). The draft underwent external review from CR societies internationally and was posted for public comment. The 14 drafted recommendations related to referral (systematic, encouragement), setting (model choice, privacy, staffing) and delivery (exercise mode, psychosocial, education, self-management empowerment). Nineteen (25.0%) survey responses were received. For all but one recommendation, ≥75% voted to include; implementability ratings were <5/7 for 4 recommendations, but only one for impact. Ultimately one recommendation was excluded, one separated into two and all revised (two substantively); one recommendation was added. Overall, certainty of evidence for the final recommendations was low to moderate, and strength mostly strong. These recommendations and associated tools can support all programs to feasibly offer some women-focused programming

Feasibility and effects of adapted cardiac rehabilitation after stroke: a prospective trial

Abstract Background Despite the cardiovascular etiology of stroke, exercise and risk factor modification programs akin to cardiac rehabilitation (CR) are not available. This study aimed to establish the feasibility of adapting a CR model for individuals with mild to moderate stroke disability. A secondary objective was to determine the program's effects on aerobic and walking capacity, and stroke risk factors. Methods A repeated measures design was used with a 3-month baseline period and 6-month adapted CR intervention (n = 43, mean ± SD age 65 ± 12 years, 30 ± 28 months post stroke). Feasibility was determined by the number of participants who completed the study, occurrence of adverse events and frequency, duration and intensity of exercise performed. To determine effectiveness of the program, outcomes measured included aerobic capacity (VO2peak, ventilatory threshold), 6-Minute Walk Test (6MWT) distance, and risk factors. Descriptive statistics characterized the classes attended and number and intensity of exercise sessions. Paired t-tests, one-factor repeated measures analyses of variance contrasts and chi-square analyses were used to compare changes over time. Results Two participants withdrew during the baseline period. Of the remaining 41 participants who commenced the program, 38 (93%) completed all aspects. No serious adverse effects occurred. Post-intervention, VO2peak improved relative to the stable baseline period (P = 0.046) and the increase in ventilatory threshold approached significance (P = 0.062). Conclusions CR is feasible after stroke and may be adapted to accommodate for those with a range of post-stroke disability. It is effective in increasing aerobic capacity. CR may be an untapped opportunity for stroke survivors to access programs of exercise and risk factor modification to lower future event risk. Trial registration ClinicalTrials.gov registration number: NCT0106749

Chronic Effects and Acute Physiological Response to Aerobic and Resistance Training in Patients Following Stroke Referred to a Cardiac Rehabilitation Program

There is compelling evidence that regular physical activity is likely to play a role in the secondary prevention of stroke and comorbid coronary artery disease. However, structured physical activity programs are not widely available for people following stroke. Cardiac rehabilitation programs (CRP) are well suited to provide exercise training following traditional stroke rehabilitation. However, people following stroke may be limited by a constellation of neurological deficits that may prevent them from effectively participating in and benefiting from an adapted CRP. Accordingly, the objectives of this work were to 1) examine the utility of cardiopulmonary exercise stress testing (CPET) for developing an exercise prescription in people ≥3 months post-stroke with mild/moderate motor impairments 2) determine ability to achieve minimal recommended exercise training levels reported to elicit health benefits during a single standard CR session following completion of a CRP 3) evaluate the physiological, and cognitive effects of a 24-week CRP of resistance and aerobic exercise and the effect of stroke-recovery-time. It was hypothesized that most patients (>50%) would reach a level of exertion on the CPET that would provide recommended exercise prescription target levels and that individuals would be able to systematically reach these target levels during a CR session. Moreover, the established exercise program would result in physiological and cognitive benefit independent of time-from-stroke. Study 1 demonstrated that most patients achieved a level of exertion during the CPET sufficient to inform an exercise prescription. In Study 2 patients with motor impairments were able to meet or exceed minimal recommended exercise target levels of intensity, duration and energy expenditure. In Study 3 a CRP yielded improvements over multiple domains of recovery (cardiovascular fitness, functional ambulation, sit-to-stand performance, and muscular strength). While those referred ≤1 year and >1 year post-stroke derived benefits from a CRP, those who started earlier (≤1 year) had greater improvements in ambulatory performance. In Study 4 combined aerobic and resistance exercise resulted in improvements in cognitive function. Change in cognition was positively associated with change in fat-free mass and change in anaerobic threshold. In summary people post-stroke are able to effectively participate in and benefit from an adapted CRP.Ph

Effect of Cardiac Rehabilitation Dose on Mortality and Morbidity: A Systematic Review and Meta-regression Analysis

OBJECTIVE: To ascertain the effect of CR dose (i.e., duration x frequency/week; categorized as low [<12 sessions], medium [12-35], or high [≥36]) on mortality and morbidity. PATIENTS AND METHODS: The Cochrane, CINAHL, EMBASE, PsycINFO and MEDLINE databases were systematically searched from inception through November30,2015. Inclusion criteria included randomized or non-randomized studies, with a minimum CR dose ≥4, and presence of a control/comparison group. Citations were considered for inclusion, and data were extracted in included studies independently by 2 investigators. Studies were pooled using random-effects meta-analysis, and meta-regression where warranted(covariates included study quality, country, publication year, and diagnosis).RESULTS: Of 4630 unique citations, 33 trials were included comparing CR to usual care (i.e., no dose).In meta-regression, greater dose was significantly related to lower all-cause mortality (high= -.77, Standard Error [SE]=.22, P<.001; medium=-0.80,SE=0.21, P<.001), when compared to low dose. With regard to morbidity, meta-analysis showed dose was significantly associated with less percutaneous coronary intervention (PCI; high: RR=.65, 95% CI .50-.84, and medium/low: RR=1.04, 95% CI .74-1.48; P=.03).This was also significant in meta-regression (high vs. medium/low=-.73, SE=.20, P<.001). Publication bias was not evident. No dose-response association was found for cardiovascular mortality, all-cause hospitalization, coronary artery bypass graft surgery, or myocardial infarction. CONCLUSION:A minimum of 36 CR sessions may be needed to reduce PCI. Future studies should examine the effect of actual dose of CR, and trials are needed comparing different doses

Prevalence of musculoskeletal comorbidities in cardiac patients: A prospective investigation of correlates and health services utilization.

Objectives: To describe the prevalence of musculoskeletal conditions (MSKC) in patients with coronary artery disease (CAD), examine the sociodemographic, clinical and psychosocial predictors of these comorbidities, and describe healthcare utilization by MSK comorbidity status. Design/Participants: 1803 patients in whom a cardiac condition was the reason for hospital admission, were administered a questionnaire in hospital and 1 year later. Setting: Eleven hospitals in Ontario, Canada. Outcome Measures: Sociodemographic, MSKC, clinical and psychosocial factors were ascertained via questionnaire and in-hospital chart extraction. A healthcare utilization questionnaire was mailed 1 year later. Results: Over half (56%) of patients with CAD had MSKCs, with arthritis/joint pain accounting for 64.4% of these MSKCs. Patients who were older (OR=1.03), female (OR=1.87), white (OR=1.80), with higher body mass index (OR=1.05), depressive symptoms (OR=1.92), and lower family income (OR=1.46) were more likely to present with MSKCs. One year post-hospitalization, a greater proportion of those with MSKCs reported ≥1 cardiac-related emergency department visit (33.2 vs. 28.3%,p=0.03), hospital admission (30.7 vs. 22%, p=0.006), more primary care physician visits (6.6 ± 5.6 vs. 5.7 ± 4.6, p<0.001) and fewer cardiac rehabilitation referrals (61.5 vs. 70%, p<0.001). After adjusting for depressive symptoms, body mass index, age, income, ethnicity, and sex, MSKCs predicted only hospital readmissions. Conclusions: Over half of patients hospitalized for CAD have MSKCs. Those with MSKCs have a physical and psychosocial profile that places them at greater cardiovascular risk than those with CAD only, explaining, in part, their greater healthcare utilization. Despite a greater need for comprehensive risk factor management in patients with MSKCs, fewer were referred to cardiac rehabilitation.Canadian Institutes of Health Research (CIHR IGH & ICRH) and The Heart and Stroke Foundation of Canada Grant # HOA-80676

Effects of high-intensity interval training on blood lactate levels and cognition in healthy adults: protocol for systematic review and network meta-analyses

Abstract Background High-intensity interval training (HIIT) has shown to confer cognitive benefits in healthy adults, via a mechanism purportedly driven by the exercise metabolite lactate. However, our understanding of the exercise parameters (e.g., work interval duration, session volume, work-to-rest ratio) that evoke a peak blood lactate response in healthy adults is limited. Moreover, evidence relating HIIT-induced blood lactate and cognitive performance has yet to be reviewed and analyzed. The primary objective of this systematic review is to use network meta-analyses to compare the relative impact of different HIIT work-interval durations, session volumes, and work-to-rest ratios on post-exercise blood lactate response in healthy adults. The secondary objective is to determine the relationship between HIIT-induced blood lactate and acute post-HIIT cognitive performance. Methods A systematic review is being conducted to identify studies measuring blood lactate response following one session of HIIT in healthy adults. The search was carried out in (1) MEDLINE, (2) EMBASE, (3) Cochrane Central Register of Controlled Trials, (4) Sport Discus, and (5) Cumulative Index to Nursing and Allied Health Literature Plus with Full Text (CINAHL+). After abstract and full-text screening, two reviewers will independently extract data on key outcomes variables and complete risk of bias assessment using the Cochrane Risk of Bias Tool and the Risk of Bias in Non-Randomized Studies of Interventions tool. Network meta-analyses will be used to generate estimates of the comparative effectiveness of blood lactate on cognitive outcomes using corresponding rankings for each work-interval duration, session volume, and work-to-rest ratio category. Where applicable, meta-regressions analyses will be performed to test the relationship between changes in the blood lactate and changes in cognitive performance. Analyses will be conducted using MetaInsight Software. Discussion This study will provide evidence on how to structure a HIIT protocol to elicit peak blood lactate response in healthy adults and will increase our understanding of the relationship between HIIT-induced blood lactate response and associated cognitive benefits. Systematic review registration PROSPERO CRD4202020440